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Public Act 92-0185
SB1341 Enrolled LRB9208220JSpc
AN ACT in relation to insurance.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Department of Insurance Law of the Civil
Administrative Code of Illinois is amended by adding Section
1405-30 as follows:
(20 ILCS 1405/1405-30)
Sec. 1405-30. Mental health insurance study.
(a) The Department of Insurance shall conduct an
analysis and study of costs and benefits derived from the
implementation of the coverage requirements for treatment of
mental disorders established under Section 370c of the
Illinois Insurance Code. The study shall cover the years
2002, 2003, and 2004. The study shall include an analysis of
the effect of the coverage requirements on the cost of
insurance and health care, the results of the treatments to
patients, any improvements in care of patients, and any
improvements in the quality of life of patients.
(b) The Department shall report the results of its study
to the General Assembly and the Governor on or before March
1, 2005.
Section 10. The Illinois Insurance Code is amended by
changing Section 370c as follows:
(215 ILCS 5/370c) (from Ch. 73, par. 982c)
Sec. 370c. Mental and emotional disorders.
(a) (1) On and after the effective date of this Section,
every insurer which delivers, issues for delivery or renews
or modifies group A&H policies providing coverage for
hospital or medical treatment or services for illness on an
expense-incurred basis shall offer to the applicant or group
policyholder subject to the insurers standards of
insurability, coverage for reasonable and necessary treatment
and services for mental, emotional or nervous disorders or
conditions, other than serious mental illnesses as defined in
item (2) of subsection (b), up to the limits provided in the
policy for other disorders or conditions, except (i) the
insured may be required to pay up to 50% of expenses incurred
as a result of the treatment or services, and (ii) the annual
benefit limit may be limited to the lesser of $10,000 or 25%
of the lifetime policy limit.
(2) Each insured that is covered for mental, emotional
or nervous disorders or conditions shall be free to select
the physician licensed to practice medicine in all its
branches, licensed clinical psychologist, or licensed
clinical social worker of his choice to treat such disorders,
and the insurer shall pay the covered charges of such
physician licensed to practice medicine in all its branches,
licensed clinical psychologist, or licensed clinical social
worker up to the limits of coverage, provided (i) the
disorder or condition treated is covered by the policy, and
(ii) the physician, licensed psychologist, or licensed
clinical social worker is authorized to provide said services
under the statutes of this State and in accordance with
accepted principles of his profession.
(3) Insofar as this Section applies solely to licensed
clinical social workers, those persons who may provide
services to individuals shall do so after the licensed
clinical social worker has informed the patient of the
desirability of the patient conferring with the patient's
primary care physician and the licensed clinical social
worker has provided written notification to the patient's
primary care physician, if any, that services are being
provided to the patient. That notification may, however, be
waived by the patient on a written form. Those forms shall
be retained by the licensed clinical social worker for a
period of not less than 5 years.
(b) (1) An insurer that provides coverage for hospital
or medical expenses under a group policy of accident and
health insurance or health care plan amended, delivered,
issued, or renewed after the effective date of this
amendatory Act of the 92nd General Assembly shall provide
coverage under the policy for treatment of serious mental
illness under the same terms and conditions as coverage for
hospital or medical expenses related to other illnesses and
diseases. The coverage required under this Section must
provide for same durational limits, amount limits,
deductibles, and co-insurance requirements for serious mental
illness as are provided for other illnesses and diseases.
This subsection does not apply to coverage provided to
employees by employers who have 50 or fewer employees.
(2) "Serious mental illness" means the following
psychiatric illnesses as defined in the most current edition
of the Diagnostic and Statistical Manual (DSM) published by
the American Psychiatric Association:
(A) schizophrenia;
(B) paranoid and other psychotic disorders;
(C) bipolar disorders (hypomanic, manic,
depressive, and mixed);
(D) major depressive disorders (single episode or
recurrent);
(E) schizoaffective disorders (bipolar or
depressive);
(F) pervasive developmental disorders;
(G) obsessive-compulsive disorders;
(H) depression in childhood and adolescence; and
(I) panic disorder.
(3) Upon request of the reimbursing insurer, a provider
of treatment of serious mental illness shall furnish medical
records or other necessary data that substantiate that
initial or continued treatment is at all times medically
necessary. An insurer shall provide a mechanism for the
timely review by a provider holding the same license and
practicing in the same specialty as the patient's provider,
who is unaffiliated with the insurer, jointly selected by the
patient (or the patient's next of kin or legal representative
if the patient is unable to act for himself or herself), the
patient's provider, and the insurer in the event of a dispute
between the insurer and patient's provider regarding the
medical necessity of a treatment proposed by a patient's
provider. If the reviewing provider determines the treatment
to be medically necessary, the insurer shall provide
reimbursement for the treatment. Future contractual or
employment actions by the insurer regarding the patient's
provider may not be based on the provider's participation in
this procedure. Nothing prevents the insured from agreeing
in writing to continue treatment at his or her expense. When
making a determination of the medical necessity for a
treatment modality for serous mental illness, an insurer must
make the determination in a manner that is consistent with
the manner used to make that determination with respect to
other diseases or illnesses covered under the policy,
including an appeals process.
(4) A group health benefit plan:
(A) shall provide coverage based upon medical
necessity for the following treatment of mental illness
in each calendar year;
(i) 45 days of inpatient treatment; and
(ii) 35 visits for outpatient treatment
including group and individual outpatient treatment;
(B) may not include a lifetime limit on the number
of days of inpatient treatment or the number of
outpatient visits covered under the plan; and
(C) shall include the same amount limits,
deductibles, copayments, and coinsurance factors for
serious mental illness as for physical illness.
(5) An issuer of a group health benefit plan may not
count toward the number of outpatient visits required to be
covered under this Section an outpatient visit for the
purpose of medication management and shall cover the
outpatient visits under the same terms and conditions as it
covers outpatient visits for the treatment of physical
illness.
(6) An issuer of a group health benefit plan may provide
or offer coverage required under this Section through a
managed care plan.
(7) This Section shall not be interpreted to require a
group health benefit plan to provide coverage for treatment
of:
(A) an addiction to a controlled substance or
cannabis that is used in violation of law; or
(B) mental illness resulting from the use of a
controlled substance or cannabis in violation of law.
(8) This subsection (b) is inoperative after December
31, 2005.
(Source: P.A. 86-1434.)
Section 99. Effective date. This Act takes effect
January 1, 2002.
Passed in the General Assembly May 02, 2001.
Approved July 27, 2001.
Effective January 01, 2002.
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